QBE INSURANCE (AUSTRALIA) LIMITED ABN 78 003 191 035 Corporate Travel Insurance Application Policy No. Client No. Intermediary No. DETAILS OF THE INSURED Name of Insured Tax Status Registered Business Yes No ABN Taxable % Address State Postcode Contact Number Phone No. (Private) ( ) Phone No. (Business) ( ) Fax No. ( ) E-mail Notices to: Name Address State Postcode Period of Insurance From / / to / / at 4 p.m. CORPORATE TRAVEL DETAILS Please indicate which trips are covered under Authorised Business Travel Overseas Australia Only Interstate Local Travel in Excess of 80 KM Please nominate insured persons and Time of Operation of Cover required Category Group 24 Hour Authorised Business Travel Other CAT 1 CAT 2 CAT 3 CAT 4 Please indicate benefits required in relation to categories shown above. Benefit CAT 1 CAT 2 CAT 3 CAT 4 Death and Capital Benefits $ $ $ $ Weekly Benefits – Injury $ $ $ $ Weekly Benefits – Illness $ $ $ $ Medical and Additional Expenses Overseas $ $ $ $ Emergency Travel Assistance $ $ $ $ Baggage and Personal Effects $ $ $ $ Money $ $ $ $ Personal Liability $ $ $ $ Kidnap and Ransom $ $ $ $ Loss of Travel Deposits and Additional Expenses $ $ $ $ Payment of Excess Following Collision Damage or Theft $ $ $ $ Other $ $ $ $ Extra Territorial Cover – Weekly $ $ $ $ Extra Territorial Cover – Any One Event $ $ $ $ Political and Other Evacuation $ $ $ $ QM227-0105 CORPORATE TRAVEL DETAILS continued Please indicate aggregate limit of liability required Schedule Flights Charter and Small Aircraft Extra Territorial Workers’ Cover $ Per Event $ Per Event $ Per any one Period of Insurance Have you ever had insurance declined or cancelled, or special terms imposed by an insurer? Yes No If "Yes", please give details. Have you ever claimed on this Class of Insurance during the last 5 years? If “Yes”, please give details. Yes No Do you or any subsidiary or associated company own or lease aircraft? If "Yes", please give details. Yes No Make of Aircraft Model Seating Capacity No. of Crew No. of Engines Do you have a company ruling limiting the number of employees who may travel together? Yes No If "Yes", please give details. Please give details of journeys involving air travel likely to be undertaken within the next 12 months. Schedule Airline Chartered Airline Private Aircraft Helicopter Number Within Australia Average Duration Number Overseas Average Duration Maximum Number of Persons Travelling Together Overseas Destinations Are there any circumstances with which the company should be made acquainted in order to form a proper estimate of the risk? If "Yes", please give details. Yes No DUTY OF DISCLOSURE The law requires you to tell us everything you know (or could reasonably be expected to know in the circumstances) which is relevant to our decision to insure you and the terms on which we insure you. This duty applies before you enter into a contract with us, that is, before we accept your proposal and also each time before you alter or renew the Policy. Each person named as the Insured has the same duty. PENALTY FOR NON-DISCLOSURE If you do not tell us everything necessary, we may: reduce or refuse to pay a claim; or cancel your Policy. If you act dishonestly, we may invalidate the Policy from its beginning and not be bound by it. You don’t need to tell us anything which: reduces the risk; is common knowledge; we already know, or ought to know in the ordinary course of our business; or we indicate we do not want to know. If you are not sure that something is relevant, it is best to disclose it anyway. PRIVACY The QBE Privacy Promise Brochure explains what sort of personal information we collect and hold about you and what we do with that information. Please contact your Financial Services Provider to obtain a copy of the QBE Privacy Promise Brochure. A copy of the brochure may also be obtained from any QBE Commercial office or from our website at www.qbecommercial.com DECLARATION AND SIGNATURE I/We declare that the particulars are true and correct, that I/We have not withheld information likely to affect the acceptance of this application. Signature of Insured(s) X X Position Held Date / / / / OFFICE USE ONLY Premium GST Government Stamp Duty TOTAL Amount Payable $ + $ + $ = $ This Policy is underwritten by QBE Insurance (Australia) Limited ABN 78 003 191 035 of 82 Pitt Street, Sydney.